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Journal of Substance Abuse Treatment Feb 2022In 2018, the Baltimore City Health Department launched a mobile clinic called Healthcare on The Spot, which offers low-threshold buprenorphine services integrated with...
INTRODUCTION
In 2018, the Baltimore City Health Department launched a mobile clinic called Healthcare on The Spot, which offers low-threshold buprenorphine services integrated with health care services to meet the needs of people who use drugs. In addition to buprenorphine management, The Spot offers testing and treatment for hepatitis C, sexually transmitted infections, and HIV, as well as pre-exposure prophylaxis for HIV, wound care, vaccinations, naloxone distribution, and case management.
METHODS AND MATERIALS
This cohort analysis includes clinical service data from the first 15 months of The Spot mobile clinic, from September 4, 2018, to November 23, 2019. The Spot co-located with the Baltimore syringe services program in five locations across the city. Descriptive data are provided for patient demographics and services provided, as well as percent of patients retained in buprenorphine treatment at one and three months. Logistic regression identified factors associated with retention at three months.
RESULTS
The Spot mobile clinic provided services to 569 individuals from September 4, 2018, to November 23, 2019, including prescribing buprenorphine to 73.8% and testing to more than 70% for at least one infectious disease. Patients receiving a prescription for buprenorphine were more likely to be tested for HIV, hepatitis C, and sexually transmitted infections, as well as receive treatment for hepatitis C and preventive services including vaccination and naloxone distribution. The Spot initiated HIV treatment for four patients and HIV pre-exposure prophylaxis for twelve patients. More than 32% of patients had hepatitis C; nineteen of these patients initiated treatment for hepatitis C with eight having a documented cure. Buprenorphine treatment retention was 56.0% at one month and 26.2% at three months. Patients who were Black or receiving treatment for hepatitis C were more likely to be retained in buprenorphine treatment at three months.
CONCLUSIONS
Increasing access to integrated medical services and drug treatment through low-threshold, community-based models of care can be an effective tool for addressing the effects of drug use.
Topics: Buprenorphine; Buprenorphine, Naloxone Drug Combination; Hepatitis C; Humans; Mobile Health Units; Naloxone; Opiate Substitution Treatment; Opioid-Related Disorders
PubMed: 34238629
DOI: 10.1016/j.jsat.2021.108553 -
Acta Medica Portuguesa May 2019All health professionals should be aware of the importance of evaluating pain - fifth vital sign- in cancer patients. Peripheral and central acting analgesics are widely... (Review)
Review
INTRODUCTION
All health professionals should be aware of the importance of evaluating pain - fifth vital sign- in cancer patients. Peripheral and central acting analgesics are widely used to treat moderate to severe pain, particularly cancer pain. Many guidelines have addressed this issue. However, real life patients' have other problems and comorbidities that may raise doubts when prescribing.
MATERIAL AND METHODS
Authors made a literature search, trying to clarify same specific situations: loss of oral route, renal impairment (hemodialysis), hepatic impairment, frequent opiod interactions and the availability of short-acting formulations.
RESULTS
The following medicines were included in this analysis: the natural opiates (morphine and codeine), their synthetic and semisynthetic derivatives (hydromorphone, oxycodone, and fentanyl), the partial agonist buprenorphine and finally tramadol and tapentadol. Transdermal systems are only available for buprenorphine and fentanyl. In hepatic impairment, fentanyl is safe, but with the exception of codeine and tramadol; other opioids should be used with caution. In renal failure: fentanyl, hydromorphone, and tapentadol are safe. Morphine should be avoided; other opioids should be used with caution. In hemodialysis, buprenorphine, fentanyl, hydromorphone and tramadol (at doses up to 200 mg/day) may be used.
DISCUSSION
Failure to recognize the impact of various situations described throughout this work, including the bioavailability due to loss of oral route, due to pharmacokinetics and pharmacodynamics of the various drugs, either in the context of the impaired metabolism or excretion, or in due to pharmacological interactions, conditions a serious risk of subtreatment of pain and consequent impact in terms of quality of life.
CONCLUSION
Opioid prescription is safe and effective, even in moderate to severe comorbidities such as renal and hepatic impairment and in patients with no oral route available. In this case, as when considering pharmacological interactions, an individualized therapeutic plan is the best solution and the patient should be assessed regularly. Unadjusted doses may relate to bad pain control and a higher prevalence of adverse events.
Topics: Administration, Oral; Analgesics, Opioid; Buprenorphine; Cancer Pain; Codeine; Deglutition Disorders; Fentanyl; Humans; Hydromorphone; Liver Failure; Morphine; Oxycodone; Renal Dialysis; Renal Insufficiency; Tapentadol; Tramadol
PubMed: 31166900
DOI: 10.20344/amp.10500 -
HPB : the Official Journal of the... Jul 2022Improved post-operative outcomes have been demonstrated in gastrointestinal procedures where a narcotic sparing strategy has been utilized. Data for... (Review)
Review
BACKGROUND
Improved post-operative outcomes have been demonstrated in gastrointestinal procedures where a narcotic sparing strategy has been utilized. Data for pancreaticoduodenectomy (PD) patients is limited. This study reviews an institutional database for outcomes based on initial analgesic strategy.
METHODS
1004 consecutive patients who underwent PD at Emory University between 2010 and 2017, were included in the analysis. Patients were divided into groups based on primary analgesic strategy employed: epidural alone (EPI), patient controlled opiate analgesia (PCA), dual (dual-PCA/EPI) and other (non-PCA/EPI). Postoperative outcomes for each group were analyzed utilizing univariate and multivariate linear regression.
RESULTS
448 (44.6%) patients were treated with EPI, 300 (29.9%) were given a PCA, 78 (7.8%) had dual-PCA/EPI and 178 (17.7%) had non-PCA/EPI analgesia. On univariate analysis, increased BMI (p = 0.030), PCA use (p < 0.001), venous thromboembolism (VTE) (p < 0.001), post-operative pancreatic fistula (POPF) (p < 0.001) and Ileus/delayed gastric emptying (DGE) (p < 0.001) were all correlated with increased LOS. On multivariate linear regression, VTE (b-coefficient 9.07, p = 0.004) POPF (8.846, p = 0.001), Ileus/DGE (4.464, p = 0.004) and PCA use (1.75, p = 0.003) were associated with significantly increased LOS.
CONCLUSION
A primary narcotic sparing strategy is associated with a significantly reduced LOS and lower rates of Ileus/DGE. Mean opiate usage was significantly lower in the EPI and non-EPI/PCA groups.
Topics: Analgesics; Gastric Emptying; Gastroparesis; Humans; Ileus; Narcotics; Opiate Alkaloids; Pancreaticoduodenectomy; Postoperative Complications; Risk Factors; Venous Thromboembolism
PubMed: 35151580
DOI: 10.1016/j.hpb.2021.12.006 -
American Journal of Obstetrics &... Aug 2020The goal of this systematic review and metaanalysis is to compare pregnancy outcomes between pregnant women undergoing treatment for opioid use disorder with... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The goal of this systematic review and metaanalysis is to compare pregnancy outcomes between pregnant women undergoing treatment for opioid use disorder with buprenorphine-naloxone and those undergoing treatment for opioid use disorder with other forms of medication-assisted treatment.
STUDY DESIGN
PubMed, Embase, PsycINFO, Cochrane Clinical Trials, and Web of Science were searched to identify studies assessing the relationship between maternal buprenorphine-naloxone use and pregnancy outcomes. Outcomes assessed included neonatal abstinence syndrome diagnosis and treatment, neonatal intensive care unit admission, length of neonatal hospital stay, delivery complications, mode of delivery, labor analgesia, illicit drug use, medication-assisted treatment dosage, gestational age at delivery, breastfeeding status, miscarriage, congenital anomalies, intrauterine fetal demise, birthweight, head circumference, length, and Apgar scores.
RESULTS
Overall, 5 studies comprising 6 study groups met the inclusion criteria. Of the 1875 mother-baby dyads available for analysis, medications prescribed as part of the medication-assisted treatment included buprenorphine-naloxone, buprenorphine alone, methadone, or long-acting opioids. There were no serious adverse maternal or neonatal outcomes associated with maternal buprenorphine-naloxone use reported among any of the studies. Women prescribed with buprenorphine-naloxone for delivered neonates who were less likely to require treatment for neonatal abstinence syndrome were compared with pregnant women prescribed with other opioid agonist medications. Of the remaining outcomes assessed, metaanalysis did not detect any statistically significant differences when comparing the groups of women using buprenorphine-naloxone with the groups of women prescribed with other medications as part of the medication-assisted treatment.
CONCLUSION
Pregnant women undergoing treatment for opioid use disorder with buprenorphine-naloxone do not experience significantly different pregnancy outcomes than women undergoing treatment with other forms of opioid agonist medication-assisted therapy.
Topics: Buprenorphine; Buprenorphine, Naloxone Drug Combination; Female; Humans; Infant; Infant, Newborn; Opiate Substitution Treatment; Pregnancy; Pregnancy Complications; Pregnancy Outcome
PubMed: 33345863
DOI: 10.1016/j.ajogmf.2020.100179 -
Surgical Endoscopy Mar 2023The ongoing epidemic of prescription opiate abuse is one of the most pressing health issues in the United States today. Consequently, analgesic adjuncts, such as...
BACKGROUND
The ongoing epidemic of prescription opiate abuse is one of the most pressing health issues in the United States today. Consequently, analgesic adjuncts, such as multimodal drug regimens and regional anesthetic blocks (like transversus abdominis plane (TAP) block), have been introduced to the perioperative period in hopes of decreasing postoperative opiate use. However, the effect of these interventions on intraoperative opiate use has not been examined. We hypothesized that preoperative TAP block would be associated with decreased intraoperative opiate use during minimally invasive cholecystectomy.
METHODS
This was a retrospective review of patients undergoing minimally invasive cholecystectomy between June 2018 and January 2021. Perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements.
RESULTS
261 patients were included in this study, of which 62 (23.8%) received preoperative TAP block and 199 (76.2%) did not. Preoperative TAP block was associated with decreased intraoperative opiate use (0.199 vs 0.312, p < 0.001), while there were no statistically significant differences associated with other analgesic adjuncts including preoperative acetaminophen (p = 0.485), celecoxib (p = 0.112), gabapentin (p = 0.165), or intraoperative ketorolac (p = 0.200). On multivariate analysis, preoperative TAP block was independently associated with decreased intraoperative opiate use (< 0.001), while chronic cholecystitis on final pathology was associated with increased intraoperative opiate use (p = 0.002).
CONCLUSION
The use of preoperative TAP block was associated with decreased intraoperative opiate use during minimally invasive cholecystectomy and should be considered for routine use. Future research should investigate whether preoperative TAP blocks and a subsequent decrease of intraoperative opiates, also result in a decrease in postoperative opiate use and improvements in postoperative outcomes.
Topics: Humans; Opiate Alkaloids; Analgesics, Opioid; Pain, Postoperative; Cholecystectomy; Morphine; Analgesics; Abdominal Muscles
PubMed: 35864354
DOI: 10.1007/s00464-022-09445-x -
Analytical Chemistry Aug 2019The opioid epidemic continues in the United States. Many have been impacted by this epidemic, including neonates who exhibit Neonatal Abstinence Syndrome (NAS). Opioid...
The opioid epidemic continues in the United States. Many have been impacted by this epidemic, including neonates who exhibit Neonatal Abstinence Syndrome (NAS). Opioid diagnosis and NAS can be negatively impacted by limited testing options outside the hospital, due to poor assay performance, false-negatives, rapid drug clearance rates, and difficulty in obtaining enough specimen for testing. Here we report a small volume urine assay for oxycodone, hydrocodone, fentanyl, noroxycodone, norhydrocodone, and norfentanyl with excellent LODs and LOQs. The free-solution assay (FSA), coupled with high affinity DNA aptamer probes and a compensated interferometric reader (CIR), represents a potential solution for quantifying opioids rapidly, at high sensitivity, and noninvasively on small sample volumes. The mix-and-read test is 5- to 275-fold and 50- to 1250-fold more sensitive than LC-MS/MS and immunoassays, respectively. Using FSA, oxycodone, hydrocodone, fentanyl, and their urinary metabolites were quantified using 10 μL of urine at 28-81 pg/mL, with >95% specificity and excellent accuracy in ∼1 h. The assay sensitivity, small sample size requirement, and speed could enable opioid screening, particularly for neonates, and points to the potential for pharmacokinetic tracking.
Topics: Analgesics, Opioid; Aptamers, Nucleotide; Fentanyl; Humans; Hydrocodone; Molecular Structure; Morphinans; Oxycodone
PubMed: 31314489
DOI: 10.1021/acs.analchem.9b01638 -
The Journal of the American Academy of... Apr 2021Opiate abuse is a public health issue linked to prescribing. Prescribing increased partly in response to adopting pain as the fifth vital sign. Assessing pain control on...
Patient Perception of Pain Control (Not Opiate Amount) Affects Hospital Consumer Assessment of Healthcare Providers and Systems and Press Ganey Satisfaction Scores After Orthopaedic Trauma.
INTRODUCTION
Opiate abuse is a public health issue linked to prescribing. Prescribing increased partly in response to adopting pain as the fifth vital sign. Assessing pain control on patient satisfaction surveys, including government-mandated Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and optional private surveys (Press Ganey) administered on hospital discharge, may contribute. This study evaluates whether opiate amounts affect orthopaedic trauma patient perception of pain control and overall hospital rating on HCAHPS and Press Ganey surveys.
METHODS
Consecutive adult patients >18 years surgically treated for isolated fractures (UE = upper extremity, LE = lower extremity, and PA = pelvis/acetabulum) at a level 1 trauma center between January 1, 2014, and December 31, 2016, were retrospectively analyzed. Hospital charts, HCAHPS, and Press Ganey data were reviewed; patients without survey responses were excluded. Data included comorbidities, psychiatric history, substance use, injury type, and surgery. Analysis included Spearman's rho for correlations, Wilcoxon rank-sum and Kruskal-Wallis for continuous variables, and adjusted ordinal regression to estimate association between opioid prescribing and patient ratings.
RESULTS
One hundred fifty-two total patients (UE 29, LE 112, and PA 11) with mean age of 57 years and median length of stay 3 days were included. Adjusted models showed longer duration outpatient prescriptions were associated with lower rating on how often inpatient pain was controlled (P = 0.002), lower total MME inpatient was associated with higher ratings (HCAHPS P = 0.015; Press Ganey, P = 0.03), lower average daily MME inpatient was associated with lower ratings (HCAHPS P = 0.008; Press Ganey, P = 0.037), and shorter outpatient prescription duration was associated with lower ratings (P = 0.008). Patient perception of pain control was strongly associated with overall HCAHPS (P < 0.05) and Press Ganey (P < 0.001) ratings.
DISCUSSION
Inpatient and outpatient opiate amounts and duration demonstrated some associations with overall scores. However, patients' pain control perception seems to have the strongest relationship with hospital rating. Counseling and multimodal pain control may lead to strong satisfaction scores without needing high opiates after orthopaedic trauma.
Topics: Adult; Analgesics, Opioid; Health Personnel; Hospitals; Humans; Middle Aged; Opiate Alkaloids; Orthopedics; Pain; Patient Satisfaction; Perception; Personal Satisfaction; Practice Patterns, Physicians'; Retrospective Studies; Surveys and Questionnaires
PubMed: 33443382
DOI: 10.5435/JAAOS-D-20-00069 -
Addiction Biology Jan 2020Opioid use disorder (OUD) is a public health crisis. Differences in opioid withdrawal severity that predict treatment outcome could facilitate the process of matching... (Randomized Controlled Trial)
Randomized Controlled Trial
Opioid use disorder (OUD) is a public health crisis. Differences in opioid withdrawal severity that predict treatment outcome could facilitate the process of matching patients to treatments. This is a secondary analysis of a randomized controlled trial (RCT) that enrolled treatment seeking heroin-users (N = 89, males = 78) into a residential study. Participants maintained on morphine (30 mg, subcutaneous, four-times daily) underwent a naloxone (0.4 mg, IM = intramuscular) challenge session to precipitate withdrawal. Area-under-the-curve (AUC) values from self-reported withdrawal ratings during the challenge session were analyzed using K-means clustering, revealing two phenotype groups. Withdrawal and retention from the subsequent 14-day double-blind, double-dummy RCT comparing three study medications (clonidine, tramadol-ER, and buprenorphine) were evaluated as a function of phenotype. Cluster analyses suggested HIGH (N = 37; mean [SD] subjective opiate withdrawal scale [SOWS]-AUC 123.7 [65.8]) and LOW (N = 52; SOWS-AUC 68.0 [47.7]) withdrawal phenotype groups. HIGH participants were significantly more female and had lower body mass indices than LOW participants; no drug-use variables were significant. Regarding RCT outcomes, HIGH phenotype participants were less likely to be retained in the study (P = 0.02) and had higher mean self-reported withdrawal (P = 0.05) than LOW phenotype participants. A significant interaction in RCT retention was observed between phenotype (P = 0.02) and study medication (P < 0.01). Self-reported withdrawal was significant for phenotype (P = 0.02); study medication trended towards significance (P = 0.07). Results suggest patients have meaningfully different experiences of opioid withdrawal that may predict differential response to opioid pharmacotherapies during supervised withdrawal. Additional prospective research to replicate and more thoroughly evaluate withdrawal phenotype correlates and sex differences is warranted.
Topics: Adult; Analgesics; Buprenorphine; Clonidine; Cluster Analysis; Double-Blind Method; Female; Humans; Male; Morphine; Naloxone; Narcotic Antagonists; Narcotics; Opiate Substitution Treatment; Opioid-Related Disorders; Phenotype; Severity of Illness Index; Substance Withdrawal Syndrome; Tramadol; Treatment Outcome
PubMed: 30295400
DOI: 10.1111/adb.12680 -
JDR Clinical and Translational Research Oct 2023In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled...
INTRODUCTION
In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids.
OBJECTIVE
The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States.
METHODS
This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation.
RESULTS
Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period.
CONCLUSION
Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain.
KNOWLEDGE TRANSFER STATEMENT
The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.
Topics: United States; Analgesics, Opioid; Hydrocodone; Tramadol; Oxycodone; Cross-Sectional Studies; Practice Patterns, Dentists'; Codeine; Drug Prescriptions
PubMed: 35708454
DOI: 10.1177/23800844221102830 -
Methods in Molecular Biology (Clifton,... 2019Buprenorphine, a synthetic opioid possessing both analgesic and opioid receptor antagonist properties, has proven to be an effective therapeutic aid for opioid...
Buprenorphine, a synthetic opioid possessing both analgesic and opioid receptor antagonist properties, has proven to be an effective therapeutic aid for opioid dependency and chronic pain management. The downside, as with all opioids, natural or synthetic, is its potential for misuse and abuse. The euphoria induced by buprenorphine leads to abuse. Additionally, individuals with an active addiction to short-acting opioids such as heroin may use buprenorphine between doses of their drug of choice to stave off withdrawal symptoms. As such, buprenorphine monitoring is utilized in medication-assisted therapy programs for opioid dependency, as well as chronic pain management settings. Buprenorphine may also be included in drug testing programs for law enforcement purposes. The assay described here was designed to detect and quantify both buprenorphine and its metabolite norbuprenorphine.
Topics: Buprenorphine; Chromatography, Liquid; Humans; Tandem Mass Spectrometry
PubMed: 30350278
DOI: 10.1007/978-1-4939-8823-5_5